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Based on interviews, record reviews, review of the facility policies, and review of 906 KAR 1:110, it was determined the facility failed to ensure compliance with all state regulations (906 KAR 1:110). The facility failed to ensure three (3) of twenty (20) patients (Patient #2, Patient #3, and Patient #4) were free from restraints imposed for convenience or punishment. The facility physically restrained Patient #2 in four-point restraints (restrained both wrists and ankles) after nursing staff attempted to remove the adolescent patient's pants and the patient became combative. The facility failed to document evidence that the use of less intrusive measures (allowing the patient to remain in his/her clothing that contained urine) posed a greater risk than the risk of using a restraint, and there was no evidence the facility considered alternatives to restraints. The facility physically restrained Patients #3 and #4; however, the facility failed to document evidence that the behavior that necessitated the use of the restraint continued to be evident. Patients #3 and #4 remained in restraints for approximately 48 hours, even though staff documented the patient was sedated. Review of nursing notes revealed approximately three hours later the patient was assessed to have sustained a skin tear to the left wrist and it was painful and swollen. Facility documentation revealed the facility attributed the injury to "the patient was very combative last night and restraints were applied."

The findings include:

A review of 906 KAR 1:110, Section 3.(5)(c) through (f) revealed a critical access hospital shall establish written policies regarding patient rights and responsibilities. The policies shall assure that each patient is informed of patient rights that include the patient's right to participate in planning his or her medical treatment; the right to be assisted in understanding his or her rights; and the right to be treated with consideration, respect, and recognition of the patient's dignity.

Review of the facility's policy titled "Patient Rights and Responsibilities," revised November 2014, revealed all patients had the right to be free from physical restraints of any form that were not medically necessary or were used as means of coercion, discipline, convenience, or retaliation by staff.

Review of the facility's policy titled "Use of Restraints," revised July 2014, revealed restraints may only be used as a medical or behavioral intervention. The policy further stated the use of medical restraints should only be used to protect the physical safety of the nonviolent or nonself-destructive patient. The decision to use a restraint should not be driven by diagnosis, but by a comprehensive individual assessment that concluded that the use of a less intrusive measure posed a greater risk than the risk of using a restraint. The policy further stated the facility should consider alternatives to restraints and discontinuation of a restraint would be initiated as early as possible when the patient's behavior that necessitated the application of restraint was no longer evident, regardless of the scheduled expiration of the order. In addition, the policy stated the patient should be monitored every two (2) hours or more often as indicated and monitoring should include the evaluation of any changes in the patient's condition that would indicate that the restraint should be removed or a less restrictive method was possible.

1. Review of the medical record for Patient #2 (a minor in the custody of the state) revealed the facility admitted the patient on 03/10/17 at 6:16 PM with a diagnosis of Overdose. According to the medical record, the facility triaged Patient #2 at 6:20 PM and documented the patient was "alert, awake and combative," and the patient stated he/she "took seven blue pills and ate some marijuana."

Continued review of Patient #2's medical record revealed at 6:25 PM on 03/10/17, Registered Nurse (RN) #2 documented "while patient was voiding [urinating] in the urinal, [he/she] voided all over pants and underwear. Patient refuses to remove pants and underwear. When attempting to remove pants, patient became very combative, hitting, spitting, kicking, screaming and using foul language. Order given to apply restraints."

Review of the order for restraints dated 03/10/17 at 6:25 PM revealed staff documented the reason for restraints was "removal of tube/equipment;" however, there was no documented evidence that Patient #2 had any tubes or medical equipment or was trying to remove them. Patient #2's medical record revealed the patient was placed in four-point soft limb restraints (restrained at both wrists and ankles) at 6:25 PM and remained in restraints until 7:15 PM. There was no evidence that the use of less intrusive measures (allowing the patient to remain in his/her clothing that contained urine) posed a greater risk than the risk of using a restraint, and no evidence the facility considered alternatives to restraints. The facility discharged Patient #2 at 8:31 PM on 03/10/17, approximately 76 minutes after the restraints were discontinued.

Interview with RN #2 on 02/22/18 at 2:10 PM revealed the facility never restrained patients for "behavioral" reasons; however, she could not explain what medical equipment or tubes Patient #2 was trying to remove when the patient was restrained on 03/10/17, after the patient would not remove his/her pants. Further interview with RN #2 revealed she attempted to remove Patient #2's pants/underwear because the patient urinated on them. RN #2 stated the patient became combative when trying to remove the patient's clothing and was restrained until his/her wet clothing could be removed. The RN stated she never considered allowing the patient to remain in his/her clothing until the patient calmed down.

2. Review of the medical record for Patient #3 revealed the facility admitted the patient on 04/26/17 at 7:54 PM with a diagnosis of Pneumonia. Further review revealed the facility placed Patient #3 in two-point soft limb restraints (restrained at the wrists) on 04/27/18 at 2:00 AM for the removal of tubes/equipment; the order did not specify a timeframe for the restraints. Patient #3's medical record revealed the facility intubated (placed a tube into the patient's airway to assist with breathing) Patient #3 on 04/27/17 at 2:15 AM and administered Diprivan (a medication used for general anesthesia and sedation).

Further review of the medical record revealed nursing staff documented from 04/27/17 at 8:00 AM until 04/29/17 at 10:00 AM (approximately 48 hours) that Patient #3 was "sleeping, sedated and intubated." However, the patient remained in restraints with no documented evidence that the behavior that necessitated the use of the restraint continued to be evident.
3. Review of the medical record for Patient #4 revealed the facility admitted the patient on 07/18/17 at 7:06 PM with a diagnosis of Intentional Overdose. Further review revealed the facility placed Patient #4 in four-point soft restraints (restrained at both wrists and ankles) on 07/18/17 at 7:07 PM because the patient "kicks and tries to pull out IV at intervals."

Continued review of Patient #4's medical record revealed the facility admitted the patient to the Intensive Care Unit at 8:30 PM on 07/18/17, and the patient was placed in two-point soft limb restraints (restrained at the wrists). Further review of the medical record revealed nursing staff documented on 07/19/17 at 12:00 AM that "the patient was resting quietly at this time" and at 3:00 AM, 4:00 AM, and 5:00 AM that Patient #4 was sleeping. However, Patient #4's restraints were not discontinued until 07/19/17 at 5:45 AM. Review of the nursing documentation on 07/19/17 at 5:45 AM, revealed there was no documented evidence that the resident was assessed when the restraints were discontinued.

Review of the nursing documentation on 07/19/17 at 8:43 AM, approximately three hours after the restraints were removed, revealed Patient #4 complained of "left hand/wrist hurting, left hand is swollen with a small skin tear to the left wrist." Continued review of the note revealed "the patient was very combative last night and restraints were applied, MD notified of hand swelling and x-ray ordered." Review of the Discharge Summary revealed on 07/19/17, the physician documented that Patient #4's "left wrist and hand were swollen this morning and x-ray was done and it was negative."

Interview with the Chief Nursing Officer (CNO) on 02/27/18 at 11:52 AM revealed she was aware of the lack of documentation justifying the need for continued restraints in Patient #3 and Patient #4's medical record. The CNO stated she was also aware that nursing staff needed to document exactly what happened in the Emergency Department and in the ICU to justify the use of restraints, as in the case of Patient #2 and the injury with Patient #4.

Based on interview, record review, and review of Medical Staff Bylaws, it was determined the facility failed to ensure two (2) of twenty (20) sampled patients (Patient #12 and Patient #13) had a current History and Physical prior to surgery.

The findings include:

Review of the Medical Staff Bylaws Rules and Regulations, undated, revealed a complete History and Physical must be completed and documented by a physician prior to surgery. The Medical Staff Bylaws stated the patient's Physician was required to complete and document a History and Physical examination within twenty-four (24) hours prior to surgery or if a History and Physical (H&P) had been completed within thirty (30) days prior to admission, the physician was required to document any changes in the patient's medical condition.

1. Review of the medical record for Patient #12 revealed the facility admitted the patient on 01/23/18 for cataract surgery of the right eye. Review of the H&P for Patient #12 revealed Physician #2 completed a H&P on 11/17/17 (approximately two months earlier), and there was no documented evidence Physician #2 conducted another H&P prior to Patient #12's surgery.

2. Review of the medical record for Patient #13 revealed the facility admitted the patient on 12/21/17 for hernia repair surgery. Review of the H&P for Patient #13 revealed Physician #3 completed the H&P on 11/27/17; however, there was no documented evidence Physician #3 updated the patient's H&P with any changes in the patient's medical condition prior to surgery.

Interview with the Operating Room (OR) Director on 02/21/18 at 1:30 PM, revealed he always checked to ensure an H&P was on the patient's chart prior to surgery; however, he did not verify that the H&P was current or if the physician had updated the H&P prior to surgery.